Airway Grand rounds WITH DR. carleton
Troubleshooting an EGD
Waveform capnography is the gold standard
Chest rise and fall
Reseat more deeply (a more common problem with the I-gel)
Back device out slightly (a more common problem with the King LT)
Change size/type of device
When to Exchange an EGD?
If it is not providing adequate oxygenation or ventilating, remove immediately and bag with facemask
If providing adequate oxygenation and ventilation weigh the following risks
Risk of ETI
Risk of displacement
Poor lung compliance
Types of EGD
Dual balloon devices vs. laryngeal mask devices
First generation (no esophageal drain) vs. second generation (esophageal drain)
How to exchange a King LT
Remove device and reintubate
Extraluminal replacement (intubating around the device)
Endoluminal replacement (intubating through the device) with either endoscopic or blind
Removing the King
Decompress the stomach using an 18F feeding tube
Consider deferring removal until after laryngoscopy
Consider exchanging under endoscopy to enhance your success
King LT Complications
Cuff pressures elevation
Tongue swelling (39%)
Gastric distension (11%)
Optimizing Direct Laryngoscopy
Positioning (ear to sternal notch)
Pre-oxygenation (less stress, longer time to intubate)
Laryngoscopy technique (blade choice and placement)
Laryngeal manipulation (utilize bimanual laryngoscopy)
Bougie (for not improvable CL-III or poor IIB view)
Keep moving your laryngoscope blade into the vallecula until you see the epiglottic twitch if you are using direct laryngoscopy, as this is a sign it has seated with the hyoepiglottic ligament.
r4 capstone WITH DR. Liebman
35% of the garbage within the country is recycled
Cincinnati itself only recycles 22.5% of garbage, much lower than its goal of recycling greater than 34% of its garbage
Try utilizing mugs for coffee instead of disposable cups in order to limit generation of excess waste
Minimizing Error in Airway Management
Acts as a verification that a task has been completed
This differs from a protocol, which is meant to lead the user to a cognitive conclusion
Why use checklists?
It allows decreased allowance on memory recall
Leads to error reduction
What are the barriers to utilizing checklists?
Operational barriers (variable circumstances, unforeseen adverse events)
Cultural (perception of admission of a weakness or skill)
Utilizing checklists in airway management
After implementation of a checklist, there was a statistically significant decrease in life-threatening complications of airway management (21% vs 34%) after implementing an airway checklist in the ICU in one study of 121 patients
The Bottom Line
Managing an airway is the most life-threatening and critical procedure we do. We should do what we can to minimize error, and utilization of a checklist can help minimize this error.
Clinical pathologic case: Guillain Barre Syndrome WITH DR. chris shaw vs. dr. kari gorder
Mononeuropathy or radiculopathy
Isolated locations to specific nerves (ex: carpal tunnel system)
Tend to be more distal and symmetric
Length dependent and progress slowly (ex: diabetic neuropathies)
Hyporeflexia and various degrees of weakness tend to predominate
Spinal cord lesions or brain lesions
May have clear spinal level
Sensory loss is typical of brain lesions
Hyperreflexia and clonus are predominant
Guillain Barre Syndrome
There is a spike in prevalence in 20-24 and 70-74 year old patients
Campylobacter species are the most commonly associated infectious precipitant of this
Antibodies are directed against myelin, causing demyelination and nerve damage
Paresthesias and areflexia are the most common presenting symptoms
When to intubate
Can they lift their head?
Can they lift their elbows?
Can they count to 20 while exhaling?
If any of these, consider intubation. Also consider when NIF <20.
Plasma exchange has a benefit
IVIG has been shown to be equivalent in benefit to plasma exchange
Treat underlying infectious causes appropriately
R1 clinical diagnostics: LBBB with stemi WITH DR. Walsh
Read Dr Walsh’s introduction post here
Why do I care?
LBBB occurs in 6.7% of patients with acute MI
LBBB obscures usual STEMI diagnosis on EKG, so can lead to a delay in care
Delayed treatment worsens outcomes with LBBB
Supra ventricular rhythm
QRS > 120 ms
Dominant S wave in V1
R-wave peak of >60ms in I, V5-V6 without Q-wave
It was developed in a retrospective case-control series of 131 patients with EKG, which was externally validated.
Derivation sample: 90% specific, 78% sensitive
Validation sample: 96% specific, 36% sensitive
Study included NSTEMI and STEMI
Sgarbossa criteria can be found here. Calculate to determine risk of MI with LBBB.
Modified Sgarbossa Criteria
Replaced absolute discordant ST evolution with ST/S ratio >-0.25
Modfiied criteria had a specificity of 90% and specificity of 91% compared with the original Sgarbossa criteria’s sensitivity of 67% and specificity of 90%
This was externally validated with a retrospective case-control study of 45 cath confirmed occlusions, and 249 cath confirmed non-occlusions, with the modified criteria having a sensitivity of 80% vs 49% and a specificity of 99% vs 100%
RV pacemaker produces LBBB due to R>L impulse
The sensitivity of “ST-segment elevation of 1 mm concordant with the QRS complex” was unable to be calculated as no ECG fit this criterion;
For “ST-segment depression of 1 mm in lead V1, V2, or V3,” the sensitivity was 19% (95% CI 11–31%), specificity 81% (95% CI 72–87%), with a likelihood ratio of 1.06 (0.63–1.64);
For “ST-segment elevation >5mm discordant with the QRS complex,” the sensitivity was 10% (95% CI 5–21%), specificity 99% (95% CI 93–99%), with a likelihood ratio of 5.2 (1.3 – 21).
Global Health guest lecturer: trauma, the neglected tropical disease WITH Dr. stephen dunlop
Road traffic accidents are the number one way US citizens will die abroad
Traffic direction such as stoplights and roundabouts are relatively uncommon in Sub-Saharan Africa
90% of traffic deaths are due to road crashes in the developing world, mostly among pedestrians, bicyclists, and motorcyclists
While war and violence play some role in trauma in the developing world, road traffic accidents are much more prevalent in the developing world ]
By the year 2030, the WHO predicts road traffic accidents (along with heart disease, COPD, and depression) will be some of the top contributors to the world’s disease burden
Road crashes cost low and middle income countries an estimated $65 billion each year, more than they receive in developmental aid
What We Can Do
Nearly 3000 people are killed on Kenyan road annually, which translates to 68 deaths per 1000 registered vehicles.
Legislation can be effective, but resources must be allocated to enforce this legislation
This compares to $600-1200 per DALY for HIV/AIDS
Allocation of funds should meet the burden of disease, including the burden of trauma